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cases where a reconstruction is a viable option.
The Bilhaut–Cloquet does not give the benecial
strength as believed because of the MCP joint
stability is improved. Furthermore, the overall
appearance is scored less, with nail appearance
being the most consistent factor [40].
The surgical techniques of Wassel type II and
type IV are discussed extensively in several textbooks. For this chapter, we would like to discuss
the treatment of different type IV thumb polydactylies. It is the most frequent type but does not
have a single approach since it appears in different forms. For the principles of treatment, see
Table9.1.
9.6.1 Radial Polydactyly at
theMCPJ (Type IV)
Type IV thumbs often demonstrate a hypoplastic
or smaller extra thumb on the radial side.
However, the degree of development and involvement of the extra thumbs varies widely, with an
extra thumb only attached with a skin pedicle, to
similar develop thumbs with deviation in the
MCPJ and IPJ.
The operative technique is based on the previously mentioned principles, with as a goal to provide in one thumb, in alignment with the rst
metacarpal, with a stable MCPJ and IPJ and with
movement along those joints in a normal fashion.
However, in the depicted end result, one should
take into account the initial situation, that is for
instance, an ulnar thumb with deviation in the
MCPJ and IPJ, deviant insertions of the tendons,
with no exion crease at the IPJ.
In Fig. 9.2, the radiographic appearance of
four type IV polydactylies is depicted.
Type IV as shown in Fig.9.2a is a type IV H r,
implying a polydactyly at the level of the MCPJ
with a hypoplastic thumb at the radial side.
Surgical correction consists of simple ablation
with inspection of the radial collateral band with
respect to stability. In these cases, reeng of this
collateral band is sometimes needed.
The thumb polydactyly shown in Fig. 9.2b
seems to be equal (type IV H r) to the extra thumb
in Fig.9.2a, however, the proximal osseous structure is more related to the rst MC, whereas this
part was not ossied at the same age in case
Fig. 9.2a. During the surgical correction, attention should be paid to the different soft tissue
connections and bony structures at the MCPJ
level. In this case, the insertion of the thenar muscles (outlined in Fig.9.3a) at the base of the radial
thumb is a giveaway for the need for more structural corrections than the rst case. The thenar
muscle attachment is dissected from the base of
the radial thumb and released more proximal to
evaluate the radial collateral band and joint sur-
ab c d
Fig. 9.2 (a–d) Four examples of type IV radial polydac-
tylies with a different aspect and therefore different surgical approaches. (a) Type IV H r, implying a polydactyly at
the level of the MCPJ with a hypoplastic thumb at the
radial side. (b) Type IV H r, similar to the extra thumb in
(a), however, the proximal osseous structure is more
related to the rst MC, implicating an additional procedure (see text). (c) Type IV D r, deviation of the radial
thumb. (d) Type IV D r u, deviation of the radial and ulnar
thumb
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C. van Nieuwenhoven and S. Hovius
a
b
cd
Fig. 9.3 (a–d) Surgical correction of a type IV D r poly-
dactyly. (a) The insertion of the thenar muscles attached at
the base of the radial thumb, and dorsal joint capsule
(lifted in pincers). (b) Metacarpal head of the radial thumb
with an insufcient radial collateral band. (c) After longitudinal osteotomy of the metacarpal head of the radial
thumb to adjust the with and prevent future osseous bulging (green). The thenar muscle and collateral band previously attached to the proximal phalanx of the radial thumb
(black). (d) After reconstruction of the collateral band and
thenar muscle to the radial base of the proximal phalanx
of the ulnar thumb
face. In this case, the radial collateral band was
insufcient and a joint surface for the radial
thumb was present (see Fig. 9.3b). Neglecting
this presence will result in an instable thumb with
an osseous prominence on the radial side at the
distal rst metacarpal level. Therefore, a longitudinal osteotomy needs to be performed (see
Fig. 9.3c) in line with the joint surface of the
ulnar thumb. The joint is stabilized by reinsertion
of the collateral band to the base of the radial side
of the ulnar thumb (see Fig.9.3d). Whereas the
previous example doesn’t need postoperative
immobilization, this case will need immobilization and protection up till 3 months after the
intervention for high-impact activities.
Postoperative protocols differ in congenital hand
centres regarding the time needed for immobilization before a period of protection with a splint
is introduced. However, it will take approximately 3months until the radial collateral band
has reached its maximal stability, and full exertion on the reconstructed ligament is allowed.
Therefore, we recommend a gradual increase in
load to this joint reconstruction, with a normal
load allowed, 3months after the operation.
The case in Fig.9.2c, type IV D r, is approached
in the same fashion as above. However, the osseous alignment of the ulnar thumb should be
inspected, as well as the insertions of the exor
and extensor tendon of the ulnar thumb.
Especially in the presence of a more distal syndactyly between the ulnar and radial thumb. In
the case of a type IV D r u, as depicted in
Fig.9.2d, a correction osteotomy of the rst MC
and basal phalanx is necessary, together with
reconstruction of the joint surface of the MCPJ,
radial collateral band of the MCPJ and IPJ, as
well as reattachment of the exor and extensor
tendons. This technique is described in detail by
the authors in different textbook chapters [41].
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9.6.2 Postoperative Care
The reconstructed thumb is immobilized for
4–6weeks, allowing nger movement in the bandage. Following the initial 4–6 weeks and
depending on the level and complexity of the
reconstruction, further treatment consists of
uninhibited full motion to a removable splint for
several weeks. The child will exercise in play,
and therefore hand therapy under supervision is
not necessary. In a simple, ‘oating type’ hypoplastic thumb polydactyly, with no reconstruction of tendons or ligaments needed, a bandage is
given for 2days, as in regular wound care.
9.6.3 Outcomes, Prognosis
andComplications
When reconstruction in a congenital hand is performed, denitive outcome can only be assessed
after growth has been completed. Therefore, it is
advisable to check children several times during
growth, preferably after growth spurts. At our
outpatient clinic, examination is performed thoroughly, in such a way that the modied JSSH
classication for postoperative results in thumb
polydactyly can be lled out [37]. Specic attention is paid to nail deformities, movement and
stability of joints, active range of motion, appearance, broadness and malalignment of the skin.
Older children and parents hardly complain of
lack of function even though joints can be stiff
[36]. Painful thumbs are very rare, although we
did see occasionally problems with sustained
writing. However, they do complain more about
appearance, after they present with an insignicant functional complaint. Especially teenagers
visit the outpatient clinic wishing for an esthetic
improvement.
Outcome can be divided into unavoidable and
avoidable results. In the unavoidable outcome in
type II, the distal part of the thumb can be from
nearly normal to hypoplastic, depending on the
initial presentation. Insufcient pulp, smaller
nails and less developed IPJs are inevitable. In
nail bed reconstructions, the nail will never be
completely normal.
Avoidable outcomes in type II relate to inappropriate alignment, resulting in nail deformities,
scarring at the nail wall, and residual nail development. If the collateral ligament is constructed
with cartilage or a small piece of bone from the
excised phalanx, new formation of bone can be
the result. At the IPJ, incongruent alignment
causes deviation, instability or stiffness. Too
much resection at the base of the distal phalanx
damages growth of the remaining distal phalanx.
In the unavoidable outcome in type IV, the
residual thumb is always lesser developed than
the normal contralateral thumb. The pulp is often
less developed, the nail is usually smaller, and
motion can vary from nearly normal to stiff,
especially at the IPJ.Goldfarb found only a difference in nail width; however, motion was not
taken into account in this study. But even though
the thumb appears smaller, patients are satised
as long as it is well-shaped.
Avoidable outcomes in type IV also relate to
inappropriate alignment. IPJ and MCPJ angulation decreases the aesthetic outcome. Deviations
at either the IP or MP joint can mostly be prevented at initial operation by aligning the articular surfaces and balancing the thumb properly.
Too much resection at the MP joint results in
growth disturbances at the proximal phalanx of
the remaining thumb. In late S- and zig-zag
deformities, proper initial alignment has not been
accomplished. Residual unstable IP- or MCPJs
can develop following improper ligamentous
reconstruction and tendon alignment at the initial
stage.
Evaluating the reported outcome in thumb
polydactyly according to the current standard is a
challenge due to the different tools used. In classifying thumb polydactyly, most will choose the
Wassel classication. But since not all thumb
polydactylies can be classied according to this
osseous anatomy-based classication, authors
choose to modify it, all in a different manner. As
a result, the base for being able to compare results
of different types of thumb polydactyly is undened, leading to incomparable evaluations of
patient groups. The second step in evaluating outcome is choosing the right outcome assessment
system, since reported results in the treatment of
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C. van Nieuwenhoven and S. Hovius
thumb polydactyly are dependent on the available tools used [39]. To be able to report valid
and generalizable outcomes, the importance of
the different items in assessment schemes should
be weighted carefully, dened by careful statistical analysis as is performed for the modied
JSSH outcome measure [37].
In an era of value-based health care, evaluating surgical result is the rst step, followed by
patient-related outcome measures such as manual
ability, participation and quality of life. The
reduced strength in thumb polydactyly patients
does not inuence their manual ability. However,
the current questionnaires available for thumb
polydactyly or hand differences as a whole are
not specic and sensitive for the detection of
activities that patients won’t be able to perform.
Are we asking the right questions? And do we
need these results in shared-decision-making?
Therefore, a group of congenital hand surgeons
worked on an ICHOM evaluation set for congenital hand differences. This will give caregivers the
opportunity to collect data on patient-reported
outcomes based on the same questionnaires, generating outcomes that will be comparable worldwide and giving direction in how to treat these
patients.
Most importantly, the primary operation for
children with thumb polydactyly is the major
one, not performing surgery before 1year of age,
correcting all differences and avoiding revision
surgery, by experienced congenital hand
surgeons.
References
1. Orioli IM, Castilla EE. Thumb/hallux duplication
and preaxial polydactyly type I. Am J Med Genet.
1999;82(3):219–24.
2. Tonkin MA, Oberg KC. The OMT classication of
congenital anomalies of the hand and upper limb.
Hand Surg. 2015;20(3):336–42.
3. Baas M, Stubbs AP, van Zessen DB, Galjaard RH,
van der Spek PJ, Hovius SER, et al. Identication
of associated genes and diseases in patients with
congenital upper-limb anomalies: a novel application of the OMT classication. J Hand Surg Am.
2017;42(7):533–45 e4.
4. Ekblom AG, Laurell T, Arner M. Epidemiology
of congenital upper limb anomalies in 562 children born in 1997 to 2007: a total population
study from Stockholm, Sweden. J Hand Surg Am.
2010;35(11):1742–54.
5. Goldfarb CA, Wall LB, Bohn DC, Moen P, Van Heest
AE.Epidemiology of congenital upper limb anomalies
in a Midwest United States population: an assessment
using the Oberg, Manske, and Tonkin classication. J
Hand Surg Am. 2015;40(1):127-32.e1-2.
6. Leung PC, Chan KM, Cheng JC. Congenital
anomalies of the upper limb among the Chinese
population in Hong Kong. J Hand Surg Am.
1982;7(6):563–5.
7. Bamshad M, Watkins WS, Dixon ME, Le T, Roeder
AD, Kramer BE, etal. Reconstructing the history of
human limb development: lessons from birth defects.
Pediatr Res. 1999;45(3):291–9.
8. Riddle RD, Tabin C. How limbs develop. Sci Am.
1999;280(2):74–9.
9. Riddle RD, Ensini M, Nelson C, Tsuchida T, Jessell
TM, Tabin C.Induction of the LIM homeobox gene
Lmx1 by WNT7a establishes dorsoventral pattern in
the vertebrate limb. Cell. 1995;83(4):631–40.
10. Riddle RD, Johnson RL, Laufer E, Tabin C. Sonic
hedgehog mediates the polarizing activity of the
ZPA.Cell. 1993;75(7):1401–16.
11. Radhakrishna U, Bornholdt D, Scott HS, Patel UC,
Rossier C, Engel H, etal. The phenotypic spectrum
of GLI3 morphopathies includes autosomal dominant preaxial polydactyly type-IV and postaxial
polydactyly type-A/B: no phenotype prediction from
the position of GLI3 mutations. Am J Hum Genet.
1999;65(3):645–55.
12. Debeer P, Peeters H, Driess S, De Smet L, Freese K,
Matthijs G, etal. Variable phenotype in Greig cephalopolysyndactyly syndrome: clinical and radiological ndings in 4 independent families and 3 sporadic
cases with identied GLI3 mutations. Am J Med
Genet. 2003;120A(1):49–58.
13. Lettice LA, Hill RE.Preaxial polydactyly: a model for
defective long-range regulation in congenital abnormalities. Curr Opin Genet Dev. 2005;15(3):294–300.
14. Swanson AB, Brown KS. Hereditary triphalangeal
thumb. J Hered. 1962;53:259–65.
15. Farooq M, Troelsen JT, Boyd M, Eiberg H, Hansen
L, Hussain MS, etal. Preaxial polydactyly/triphalangeal thumb is associated with changed transcription
factor-binding afnity in a family with a novel point
mutation in the long-range cis-regulatory element
ZRS.Eur J Hum Genet. 2010;18(6):733–6.
16. Wieczorek D, Pawlik B, Li Y, Akarsu NA, Caliebe A,
May KJ, etal. A specic mutation in the distant sonic
hedgehog (SHH) cis-regulator (ZRS) causes Werner
mesomelic syndrome (WMS) while complete ZRS
duplications underlie Haas type polysyndactyly and
preaxial polydactyly (PPD) with or without triphalangeal thumb. Hum Mutat. 2010;31(1):81–9.
9 Thumb Polydactyly
https://t.me/medicina_free
111
17. Klopocki E, Ott CE, Benatar N, Ullmann R, Mundlos
S, Lehmann K.A microduplication of the long range
SHH limb regulator (ZRS) is associated with triphalangeal thumb-polysyndactyly syndrome. J Med
Genet. 2008;45(6):370–5.
18. Sun M, Ma F, Zeng X, Liu Q, Zhao XL, Wu FX, etal.
Triphalangeal thumb-polysyndactyly syndrome and
syndactyly type IV are caused by genomic duplications involving the long range, limb-specic SHH
enhancer. J Med Genet. 2008;45(9):589–95.
19. Wassel HD. The results of surgery for polydactyly of the thumb. A review. Clin Orthop Relat Res.
1969;64:175–93.
20. Zuidam JM, Selles RW, Ananta M, Runia J, Hovius
SE. A classication system of radial polydactyly:
inclusion of triphalangeal thumb and triplication. J
Hand Surg Am. 2008;33(3):373–7.
21. Kim JK, Al-Dhafer BAA, Shin YH, Joo
HS. Polydactyly of the thumb: a modication of
the Wassel-Flatt classication. J Hand Surg Eur.
2021;46(4):346–51.
22. Buck-Gramcko D. Congenital malformations of the
hand and forearm. Chir Main. 2002;21(2):70–101.
23. Upton J, Shoen S. Triphalangeal thumb. In: Gupta
A, Kay SP, Scheker LR, editors. The growing hand,
diagnosis and management of the upper extremity in
children. 1st ed. London: Mosby; 2000. p.255–68.
24. Hu CH, Thompson ER, Agel J, Bauer AS, Moeller
AT, Novotny SA, etal. A comparative analysis of 150
thumb polydactyly cases from the CoULD registry
using the Wassel-Flatt, Rotterdam, and Chung classications. J Hand Surg Am. 2021;46(1):17–26.
25. Dijkman RR, van Nieuwenhoven CA, Hovius SE,
Hulsemann W. Clinical presentation, surgical treatment, and outcome in radial polydactyly. Handchir
Mikrochir Plast Chir. 2016;48(1):10–7.
26. Saito S, Tsuge I, Yamanaka H, Morimoto N.Soft tissue abnormalities in Wassel type VI radial polydactyly: a detailed anatomical study. J Hand Surg Eur.
2021;46(4):352–9.
27. Crowley B, Stevenson S, Diogo R. Radial polydactyly: putting together evolution, development and
clinical anatomy. J Hand Surg Eur. 2019;44(1):51–8.
28. Dautel G, Perrin P. Use of an axial ap to increase
the girth of Wassel IV thumb reconstructions. J Hand
Surg Am. 2015;40(7):1327–32.
29. Horii E, Hattori T, Koh S, Majima M. Reconstruction for Wassel type III radial polydactyly
with two digits equal in size. J Hand Surg Am.
2009;34(10):1802–7.
30. Engelhardt TO, Baur EM, Pedross F, Piza-Katzer
H. Supporting the collateral ligament complex in
radial polydactyly type Wassel IV. J Plast Reconstr
Aesthet Surg. 2013;66(1):104–12.
31. Xu YL, Shen KY, Chen J, Wang ZG. Flexor pollicis longus rebalancing: a modied technique for
Wassel IV-D thumb duplication. J Hand Surg Am.
2014;39(1):75–82 e1.
32. Stutz C, Mills J, Wheeler L, Ezaki M, Oishi S.Longterm outcomes following radial polydactyly reconstruction. J Hand Surg Am. 2014;39(8):1549–52.
33. Patel AU, Tonkin MA, Smith BJ, Alshehri AH,
Lawson RD. Factors affecting surgical results of
Wassel type IV thumb duplications. J Hand Surg Eur.
2014;39(9):934–43.
34. Ogino O, Tsuchida H, Kashiwa H, Ishigaku D,
Takahara M. Thumb polydactyly. Tech Hand Up
Extrem Surg. 1999;3(4):278–85.
35. Goldfarb CA, Patterson JM, Maender A, Manske
PR. Thumb size and appearance following reconstruction of radial polydactyly. J Hand Surg Am.
2008;33(8):1348–53.
36. Dijkman R. Radial polydactyly: double or nothing?
Rotterdam: Erasmus University; 2016.
37. Dijkman R, Selles R, van Rosmalen J, Hulsemann W,
Mann M, Habenicht R, et al. A clinically weighted
approach to outcome assessment in radial polydactyly. J Hand Surg Eur. 2016;41(3):265–74.
38. Dijkman RR, van Nieuwenhoven CA, Selles RW,
Habenicht R, Hovius SE.A multicenter comparative
study of two classication systems for radial polydactyly. Plast Reconstr Surg. 2014;134(5):991–1001.
39. Dijkman RR, van Nieuwenhoven CA, Selles RW,
Hovius SE. Comparison of functional outcome
scores in radial polydactyly. J Bone Joint Surg Am.
2014;96(6):463–70.
40. Dijkman RR, Selles RW, Hulsemann W, Mann M,
Habenicht R, Hovius SE, etal. A matched comparative study of the Bilhaut procedure versus resection
and reconstruction for treatment of radial polydactyly
Types II and IV.J Hand Surg Am. 2016;41(5):e73–83.
41. Hovius S, van Nieuwenhoven CA.Congenital hand
IV: syndactyly, synostosis, polydactyly, camptodactyly, and clinodactyly. In: Chang J, Neligan PC, editors. Plastic surgery. 4th ed. Elsevier; 2018.
Ulnar Polydactyly
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ScottN.Oishi andTerriBeckwith
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Abstract
Ulnar polydactyly is the most common form
of polydactyly among the pediatric population. The polydactylous digits are developmentally classied as Type A or Type B, with
Type B more prevalent. Type A is more rare
and is occasionally associated with syndromic
conditions, thus a thorough initial evaluation
is mandatory to assess for the possible associated ndings. For those patients requiring
general anesthesia (Type A and wide-based
Type B), delay until at least 1year of age is
recommended to decrease potential anesthesia
risk. Many Type B ulnar polydactylies can be
treated in the clinic without the use of general
anesthesia and can be performed within days
of birth. The appropriate evaluation of these
patients is mandatory in order to provide the
best reconstructive option for them.
S. N. Oishi (*)
Texas Scottish Rite Hospital for Children,
Dallas, TX, USA
e-mail: Scott.Oishi@tsrh.org
T. Beckwith (*)
Center for Excellence in Hand, Upper Extremity and
Microvascular Surgery, Texas Scottish Rite Hospital,
Dallas, TX, USA
e-mail: Terri.Beckwith@tsrh.org
Keywords
Ulnar polydactyly · Postaxial · Pediatric hand
Congenital hand · Type A · Type B
10.1 Introduction
Ulnar polydactyly is a congenital hand difference
frequently encountered in a pediatric hand surgery practice. The incidence is estimated at about
1in 1300 live births [1].
The general classication system currently
used was developed by Temtamy and McKusick
[2]. They categorized them into Type A and Type
B based on the development of the polydactylous
digit. Type B refers to a supernumerary digit that
is rudimentary and loosely attached. Type A
refers to a polydactylous digit that is welldeveloped and connects to the bony elements of
the hand. Type B ulnar polydactyly is much more
common than Type A and occurs ten times as frequent in individuals of African descent in which
the incidence is 1in 100 to 300 live births compared to 1in 1500 to 3000in white children [3].
The incidence of Type A is equal between individuals of African descent and Caucasians [4].
In general, Type B ulnar polydactyly is an isolated nding which can have a strong autosomal
dominant inheritance pattern, affecting the feet as
well as the hands. In contrast, Type A ulnar polydactyly has been associated with syndromes such
as Greig’s, Bardet–Biedl, Ellis–van Creveld,
© Springer Nature Switzerland AG 2023
G. Pajardi (ed.), Pediatric Hand Surgery, https://doi.org/10.1007/978-3-031-30984-7_10
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Table 10.1
Type A Ulnar
Polydactyly
Subgroup
Number of patients 19 20 4 5 4 2 49
Patients with
bilateral Type A
ulnar polydactyly
Patients with same
subgroup type
bilaterally
Patients with
contralateral Type B
ulnar polydactyly
Patients with
combined hand and
foot postaxial
polydactyly of the
feet
a
Because of bilateral Type A cases with two different subtypes, the total number of patients does not match the summa-
tion of the different subtypes
Smith–Lemhi-Optic, McKusick–Kaufmann, and
others [5].
tation of patients with Type A ulnar polydactyly
and classied them based on bony anatomy
(Table 10.1) [6]. Interestingly, they also found
that in patients with bilateral involvement the
type of ulnar polydactyly was not necessarily
symmetric.
Subtypes of Type A ulnar polydactyly of the hand [6]
Metacarpal
type
(Type I)
12 (63%) 4 (20%) 1 (25%) 2 (40%) 3 (75%) 1 18
7 0 1 1 3 1 13
7 8 0 0 1 0 16
19 10 1 3 2 1 31
Metacarpophalangeal
type (Type II)
Pritsch etal. reviewed the phenotypic presen-
Fully
Phalangeal
type
(Type III)
Intercalated
type
(Type IV)
developed
type
(Type V) Unclassied Total
As stated above, in patients with Type A ulnar
polydactyly, a thorough examination must be
performed as craniofacial, musculoskeletal, cardiac, renal, reproductive, and visual anomalies
may be present warranting further investigation.
In patients with any of these associated ndings,
a referral to a geneticist would be appropriate.
An example of this is Ellis Van Creveld syndrome (chondroectodermal dysplasia) where
patients have characteristic nail, hair, and teeth
anomalies in addition to the ulnar polydactyly
10.2 Evaluation
(Fig.10.1).
More importantly greater than 50% of these
Hand surgeons are often the rst practitioners to
see these patients after birth. Although in many
instances the ulnar polydactyly is an isolated
nding, it is imperative to perform a thorough
history and physical examination on these
patients at initial evaluation. In African American
children, a strong family history of ulnar polydactyly is frequently encountered. Lower extremity evaluation will also frequently reveal postaxial
polydactyly.
patients have a congenital heart defect and can
also have cryptorchidism (males), chest, and
spine anomalies.
In patients with straightforward narrow-based
Type B ulnar polydactyly, radiographs are not
necessary and treatment can easily be performed
in the clinic setting. In patients that require surgical reconstruction, radiographs taken just prior to
surgery are mandatory, especially in patients with
Type A that will require more than just excision.
a
a
a
ab
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c
d
Fig. 10.1 Chondroectodermal Dysplasia (a, b), clinical
appearance of a patient with chondroectodermal dysplasia. Note the brachydactyly and small nails. (c)
Radiographs showing the short, broad middle phalanges
and hypoplastic distal phalanges. (d) Clinical appearance
of sparse, ne-textured hair and short upper lip
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S. N. Oishi and T. Beckwith
10.3 Treatment
At rst evaluation patients with Type B, ulnar
polydactyly must be assessed for suitability of
treatment at that setting. Broad-based polydactylous digits are best left until after a year of age
when the anesthetic risks related to safety issues
sufciently decrease (Fig.10.2).
In patients with narrow-based polydactyly,
several options exist. Suture ligature has been
used with reliable results as far as the removal of
the digit. However, signicant scarring and neuroma formation has been reported in up to 23.5%
of cases (Fig.10.3).
Our preferred method is shown in Fig.10.4.
The base is injected with 1% lidocaine then 2–3
appropriately size ligaclips are applied as shown.
A gauze bandage is then wrapped around the
area and the patient is seen back in 2 weeks.
When the bandage is removed, usually the digit
has already auto-amputated. If there is still some
adherence of the digit, an 18-gauge needle bevel
can be used for nal removal. This procedure can
be easily performed in the clinic and offers large
cost savings when compared to an outpatient surgical procedure.
In our review of patients treated at our institution with ligaclip, application the incidence of
neuroma formation was 7%, which is signicantly less than that reported with the suture ligation technique [7]. No matter which technique is
utilized near-normal function of the little nger is
to be expected.
Fig. 10.2 Type B post-axial polydactyly. (a, b) Example of broad-based polydactyly not amenable to removal with
suture ligature or ligaclip application
Fig. 10.3 (a, b) Neuroma formation after suture ligation
ab
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c
d
e
Fig. 10.4 Technique of ligaclip application. (a) Narrow-based Type B postaxial polydactyly. (b) Injection of the base
with 1% lidocaine. (c, b) Application of ligaclips to base of digit. (e) Two weeks after ligaclip application
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